Portland is known for being queer-inclusive. But it still has work to do in meeting the mental health care needs of LGBTQ people—especially transgender and gender-nonconforming people, who can be the most vulnerable.

Raina Daniels, a program manager at Portland's Q Center, says access to health care—and especially to mental health care—can be hard to obtain.

The services can be prohibitively expensive, and many therapists don't feel confident working with people who are seeking gender affirming care. "There's only a small number of providers who occupy those identities themselves," Daniels says.

(Resource:If you are a provider seeking training, consider SMYRC's Bridge 13, an educational program that helps participants examine the stereotypes and assumptions that fuel discrimination and/or harassment against LGBTQ folks.)

"Overall, anxiety is high—anxiety around whether or not insurance will disappear, safety walking down the street," Guerriero says. "Anything from thinking about flying across the country and being subject to additional scrutiny by [the Transportation Security Administration] to, in Portland, not being able to access a bathroom for fear of safety. Every time a news article comes out about someone's death or a change in policy, [OHSU's Transgender Health Program] gets an influx of phone calls—people looking for reassurance."

This spring, the LGBTQ community has been shaken by sudden losses.

Patch, a local 27-year-old video game designer, died in May by suicide. Last year, Patch became the first person in the nation to win the legal right to a name change and official recognition as agender. Patch told reporters covering the legal decision that pronouns—even gender-neutral ones like "they" and "them"—did not feel right.

"What describes me is my name," Patch said.

In recent months, Patch had struggled to pay rent in Portland. An online fundraising campaign asked people to help pay Patch's rent. But a post about Patch's death on Facebook says an eviction notice was posted in May on Patch's apartment door.

The same month, Gigi Eugene-Pierce, a transgender woman who struggled to find treatment for her alcohol and drug addiction, was fatally shot on a downtown street.

Such tragedies do not occur in a vacuum, but are symptoms of trans identities being erased, dismissed or made the basis for justifying violence.

The National Alliance on Mental Illness says LGBTQ youth are four times more likely than cisgender youth to attempt suicide, experience suicidal ideation or self-harm. Transgender people tend to report higher instances of depression and anxiety, and surveys have shown that between one- and two-thirds of trans people consider suicide at some point in their lives.

It doesn't help that mental health services for the LGBTQ community have a checkered past.

For decades, homosexuality was defined as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders, which psychologists use to diagnose patients. Some parents still send gay and lesbian teenagers to "conversion therapy" to try to change their sexual orientation through what often amounts to physical and psychological torture.

Guerriero says that for transgender, non-binary and gender-nonconforming people, mental health care has also been used as a barrier to other services.

"It's a double-edged sword," Guerriero says. "There is a long history of therapy [being used as] a gatekeeper to services that has led to distrust within the community. There are therapists out there who would require a certain number of sessions to see someone before supporting their transition, and others who might unintentionally give someone the message that they are not trans enough."

But in recent years, access to LGBTQ-focused health care has improved.

New standards of care as written by the World Professional Association for Transgender Health were recently published with more attention to the non-binary experience, Guerriero says.

"People are being recognized and affirmed as gender-nonconforming and charting their own course when it comes to transitioning," they say, adding that peoples in those categories no longer have to "recite a narrative of desiring to go from point A to point B" to receive treatment.

In Portland, LGBTQ-serving health center Prism Health opened its doors last year, offering primary care, free testing for sexually transmitted infections and access to pre-exposure prophylaxis, or PrEP, the daily pill that can dramatically reduce a person's likelihood of contracting HIV. At least three of the major Portland-area hospital systems—Legacy Health, Oregon Health & Science University and Kaiser—have designated transgender health programs.

"The trans community is resilient," says Guerriero. "Lately, it's felt like a lot of onslaught—but we bend, we don't break. And we wrap support around each other."

Brave Space:305-486-8936, bravespacellc.com. A collective of local mental and physical health providers dedicated to serving transgender, non-binary and gender nonconforming folks and their families.

Sexual and Gender Minority Youth Resource Center (SMYRC):503-872-9664, smyrc.org. Drop in support and activity center, with locations in in downtown Portland and Gresham, for gender diverse youth and their families.

Quest Center:503-238-5203, quest-center.org. A multidisciplinary health center that offers LGBTQ health services, as well as substance addiction treatment programs and health support for those living with HIV.